1 Survey

Source: EPA, NHANES, IFPS Visits: Within X Days of P1, T1, and T3 Mode: Self-administered Estimated Time: 5 minutes		BAR CODE LABEL OR SUBJECT ID HERE |___|___|___|___|___|___|___|___|

National Children’s Study

3-Day Food Checklist

P1/T1 and T3

Instructions!

1	This booklet contains 3 Food Checklists and Instructions.
2	Fill out one Food Checklist throughout the day on the next: [PUT LABEL HERE WITH DAYS] [EITHER TH, F, SA OR SU, M, TU]
3	Each Food Checklist asks about some (but NOT all) of the foods you eat.
4	Each Food Checklist asks about how many different times you eat a food each day (NOT how many pieces or servings you eat each time).
5	Complete the Checklist each day by checking a box each time you eat a food on that day.
6	Use only a black ball-point pen (not red ink or felt tip) to mark your foods. If you make a mistake, cross out the incorrect answer.

How to Record Foods

Check (_) a box for every food you eat at a different meal or snack.

Example: I drank 1 glass of whole milk for breakfast and 1 glass for a snack in the afternoon.





            Milk whole (include chocolate milk)

Do NOT count the number of pieces or servings of the same food you eat at a meal or snack.

Example: I ate 2 pieces of cornbread for lunch.



            Corn cereal or bread

Record mixtures (sandwiches, casseroles, salads, pasta and stir-fry dishes) by checking each food in the mixture)

Example: I ate a turkey sandwich (2 slices of white bread, lettuce, tomato, and mayonnaise).



            Bread, white



            Turkey



            Lettuce



            Tomato

Example: I ate lasagna with tomato sauce with ground beef.



            Pasta noodles



            Beef



            Tomato

Example: I ate a lettuce salad with onion, cucumber, and carrots.



            Lettuce



            Onion



            Cucumber



            Carrots

1	Please enter today’s DATE ____ / ___ / ____ (month/day/year)
2	What day is TODAY?  Monday  Tuesday  Wednesday  Thursday  Friday  Saturday  Sunday
3	Now fill in the foods you eat today in the boxes below.

Dairy (include flavored milks such as chocolate milk)
Milk whole
Milk 2%
Milk 1%
Milk skim
Other milk (soy, rice, or other milk)
Yogurt (all kinds)

Beverages
Apple juice
Grape juice
Orange juice
Wine
Beer
Coffee, regular
Green Tea (hot or iced)
Water, tap
Water, filtered
Water, bottled

Cereal, Breads and Grains
Corn cereal or bread
Oatmeal
Rice, white
Pasta noodles
Bread, white
Bread, whole wheat
Barley
Other grains

Fruits
Apple with peel
Banana
Cantaloupe
Grapes
Orange
Peaches
Strawberries
Watermelon
Other fruits

Vegetables
Beans, green
Broccoli
Carrots
Cucumber
Corn
French fries
Lettuce
Onion
Peas
Potatoes (no peel)
Potatoes (with peel)
Tomatoes
Other vegetables

Sweets
Ice cream
Cookies
Sugar
Hard candy
Other sweets

Eggs, Fish, Poultry and Meat
Eggs
Fish or shellfish
Chicken
Turkey
Beef
Pork
Other meats

Peanut Butter and Nuts
Peanut butter
Nuts (all kinds)

4	Think about the fruits and vegetables you ate today. About how many of those foods were labeled “organic”?
	All  Some  Most  None

This page intentionally blank.

1	Please enter today’s DATE ____ / ___ / ____ (month/day/year)
2	What day is TODAY?  Monday  Tuesday  Wednesday  Thursday  Friday  Saturday  Sunday
3	Now fill in the foods you eat today in the boxes below.

Dairy (include flavored milks such as chocolate milk)
Milk whole
Milk 2%
Milk 1%
Milk skim
Other milk (soy, rice, or other milk)
Yogurt (all kinds)

Beverages
Apple juice
Grape juice
Orange juice
Wine
Beer
Coffee, regular
Green Tea (hot or iced)
Water, tap
Water, filtered
Water, bottled

Cereal, Breads and Grains
Corn cereal or bread
Oatmeal
Rice, white
Pasta noodles
Bread, white
Bread, whole wheat
Barley
Other grains

Fruits
Apple with peel
Banana
Cantaloupe
Grapes
Orange
Peaches
Strawberries
Watermelon
Other fruits

Vegetables
Beans, green
Broccoli
Carrots
Cucumber
Corn
French fries
Lettuce
Onion
Peas
Potatoes (no peel)
Potatoes (with peel)
Tomatoes
Other vegetables

Sweets
Ice cream
Cookies
Sugar
Hard candy
Other sweets

Eggs, Fish, Poultry and Meat
Eggs
Fish or shellfish
Chicken
Turkey
Beef
Pork
Other meats

Peanut Butter and Nuts
Peanut butter
Nuts (all kinds)

4	Think about the fruits and vegetables you ate today. About how many of those foods were labeled “organic”?
	All  Some  Most  None

This page intentionally blank.

1	Please enter today’s DATE ____ / ___ / ____ (month/day/year)
2	What day is TODAY?  Monday  Tuesday  Wednesday  Thursday  Friday  Saturday  Sunday
3	Now fill in the foods you eat today in the boxes below.

Dairy (include flavored milks such as chocolate milk)
Milk whole
Milk 2%
Milk 1%
Milk skim
Other milk (soy, rice, or other milk)
Yogurt (all kinds)

Beverages
Apple juice
Grape juice
Orange juice
Wine
Beer
Coffee, regular
Green Tea (hot or iced)
Water, tap
Water, filtered
Water, bottled

Cereal, Breads and Grains
Corn cereal or bread
Oatmeal
Rice, white
Pasta noodles
Bread, white
Bread, whole wheat
Barley
Other grains

Fruits
Apple with peel
Banana
Cantaloupe
Grapes
Orange
Peaches
Strawberries
Watermelon
Other fruits

Vegetables
Beans, green
Broccoli
Carrots
Cucumber
Corn
French fries
Lettuce
Onion
Peas
Potatoes (no peel)
Potatoes (with peel)
Tomatoes
Other vegetables

Sweets
Ice cream
Cookies
Sugar
Hard candy
Other sweets

Eggs, Fish, Poultry and Meat
Eggs
Fish or shellfish
Chicken
Turkey
Beef
Pork
Other meats

Peanut Butter and Nuts
Peanut butter
Nuts (all kinds)

4	Think about the fruits and vegetables you ate today. About how many of those foods were labeled “organic”?
	All  Some  Most  None

This page intentionally blank.

5	In the past month, did you always, usually, sometimes, or seldom:

		Always	Usually	Sometimes	Seldom
	a. Wash your hands before preparing food for your family?
	b. Wash the cutting board or counter before preparing food on it for your family?
	c. Wash or rinse fresh fruits and vegetables at least 20 seconds and drain 2 minutes before preparing them for your family?

Comments

Did you have any difficulty understanding how to fill out the Food Checklists? If so, please explain.

Thank you very much for completing the 3-Day Food Checklists. All of your answers are very important to the study.

IF P1 OR T1: We will pick up the booklet when we return next week to pick up the air samples.

IF T3: Please return your booklet in the envelope provided.
If your envelope has been misplaced, mail your booklet to:

(space for label)

Appendix A A.2.1.a–7